Calum Paton’s article reads like a howl of pain when faced with the history of the past 20 years of ‘market-like’ reform to the NHS and the prospect of what is to come. Typically, he makes some powerful points. Not least, he highlights some of the unresolved tensions in current health policy. It does indeed remain pretty much of a mystery quite how patient choice, practice-based commissioning, and commissioning by primary care trusts will knit together, let alone how all NHS Trusts, foundation or not, are meant to make a profit (surplus) within a cash-limited system. But, while his article contains a litany of the problems, both actual and potential, that the ‘new NHS’ may bring, it is missing a counter factual. It contains an unspoken assumption that these changes are being made, almost willfully, to a system that was functioning, if not perfectly, then pretty well.